Chart 1.  Treatment guidelines for Premenstrual Dysphoric Disorder (PMDD)

Undertake a careful medical and psychiatric history.  Rule-out or treat any physical disorders (e.g. hypothyroidism).

If premenstrual symptoms remain, obtain prospective mood ratings for 2-3 months. Rule-out premenstrual exacerbation of other psychiatric conditions.

Diagnose with PMDD if the patient meets criteria after two consecutive cycles.  Encourage supportive counseling that advocates lifestyle adjustments during vulnerable premenstrual times.  Assess type and severity of symptoms.

Mild symptoms:  use vitamins, minerals, evening primrose oil, or a diuretic  
·    May be taken for only part of the cycle (midcycle to the onset of menses)
·    
Vitamin B6: 25-100 mg per day (start with 25-50 mg per day; not to exceed
    100 mg per day)

·    Optivite, calcium, or magnesium may also have positive effects on mood
·    Potassium-sparing diuretics (e.g. hydrochlorothiazide 25 mg, triamterene 50 mg)
    are appropriate if a woman has significant weight gain premenstrually; monitor
    electrolytes closely
·    Bromocriptine in dosages of 1.25-7.5 mg per day may be appropriate if breast
    pain is a significant concomitant symptom

Moderate to severe symptoms:  use psychotropic drugs or hormonal therapy
·    Improvement typically requires 2-4 months of treatment
·    SSRIs (e.g. fluoxetine 20-40 mg per day starting at 20 mg for 2-3 cycles,
    sertraline 50-100 mg per day,  clomipramine 25-75 mg per day, etc.) appear
    to be effective; consider intermittent dosing (e.g. from midcycle to the onset of
    menses) with significant side effects
·    Nortriptyline also may be beneficial
·    Hormonal options (e.g. GnRH agonists, danazol, and estradiol) may be effective
    but are not recommended as there currently is insufficent data about their safety
    in long-term use; progesterone and oral contraceptives do not appear to have a
    beneficial effect on depressive symptoms
·    Lithium or other mood stabilizers may be effective for recurrent, suicidal
    depression (check levels at different menstrual cycle phases)

Anxious symptoms prominent with secondary dysphoria:  use anxiolytics
·    Alprazolam (start at .25 mg per day and increase as necessary; do not exceed
    4 mg per day; taper at the onset of menses by 25% per day) can be given
    during days 12-28 of the cycle
·    Clonazepam may be helpful for patients who cannot tolerate the abrupt tapering
·    Benzodiazepines may be used with caution during symptomatic days
·    Buspirone (start at 5 mg three times per day) may be used throughout the cycle
    or from midcycle to the onset of menses

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published 2000